Turkish Journal of Geriatrics 2014; 17 (3) 312-315
Gülen DEM‹RPOLAT
Bal›kesir Üniversitesi T›p Fakültesi Radyoloji Anabilim Dal› BALIKES‹R Tlf: 0266 612 10 10 e-posta: gulendemirpolat@hotmail.com Gelifl Tarihi: 15/04/2014 (Received) Kabul Tarihi: 30/06/2014 (Accepted) ‹letiflim (Correspondance)
1 Bal›kesir Üniversitesi T›p Fakültesi Radyoloji Anabilim Dal› BALIKES‹R
2 Bal›kesir Üniversitesi T›p Fakültesi Gö¤üs Hastal›klar› Anabilim Dal› BALIKES‹R
Gülen DEM‹RPOLAT1 Nurhan SARIO⁄LU2 Bahar YANIK1
Erdo¤an BÜLBÜL1
NONTHROMBOTIC PULMONARY ARTERY
EMBOLISM IN AN ELDERLY PATIENT:
HYDATID CYST
YAfiLI B‹R HASTADA NONTROMBOT‹K
PULMONER ARTER EMBOL‹S‹: K‹ST H‹DAT‹K
A
BSTRACTA
pulmonary artery embolism related to hydatid disease is extremely rare. Although isolated cases have been reported, it is usually due to a hepatic lesion invading the hepatic veins or inferior vena cava, or a direct embolism from right cardiac lesions. Patients may present with hemoptysis, dyspnea, chest pain, acute cor pulmonale, or sudden death. The diagnosis is made from a medical history, clinical findings and computed tomography imaging. The computed tomography shows single or multiple cystic lesions leading to a filling defect or obstruction in the pulmonary arteries. In this article we present a 76-year-old woman with multiple lung lesions and a bilateral pulmonary artery embolism. In this case the pulmonary artery embolism was consid-ered to be secondary to the invasion of the inferior vena cava by the liver lesion.Key Words: Pulmonary Arteries; Pulmonary Embolism; Hydatidosis; Echinococcosis, Hepatic;
Echinococcosis; Pulmonary.
Ö
ZK
ist hidati¤e ba¤l› pulmoner arter embolisi çok nadir izlenir. ‹zole olgular bildirilmifl olsa da,genellikle karaci¤erdeki bir lezyonun hepatik venlere veya vena kava inferiyora aç›lmas›yla ya da sa¤ kalpteki lezyonlar›n embolisiyle oluflur. Hastalar klini¤e hemoptizi, dispne, gö¤üs a¤r›s›, kor pulmonale veya ani ölümle gelebilir. Tan› öykü, klinik bulgular ve bilgisayarl› tomografi görün-tüleme ile koyulur. Bilgisayarl› tomografide pulmoner arterlerde dolum defekti veya t›kanma oluflturan tek veya çok say›da kistik lezyon saptan›r. Bu makalede çok say›da akci¤er lezyonu ve bilateral pulmoner arter embolisi olan 76 yafl›ndaki kad›n hasta sunulmaktad›r. Bu olguda pul-moner arter embolisinin vena kava inferiyorun karaci¤erdeki lezyon taraf›ndan invaze edilmesine ba¤l› oldu¤u düflünülmüfltür.Anahtar Sözcükler: Pulmoner Arterler; Pulmoner Emboli; Hidatidozis; Hepatik Ekinokok;
Pulmoner Ekinokok
O
LGUS
UNUMUC
ASER
EPORTI
NTRODUCTIONE
chinoccocosis is a parasitic disease, endemic in someregions of the world. It is manifested as cystic and solid-appearing masses in virtually any organ. The lung is the sec-ond most common site of cyst development after the liver (1). Lung involvement is usually isolated but may be concomitant with liver disease.A pulmonary artery embolism is an uncommon complica-tion and is caused by the cystic form of echinococcus granulo-sus. The parasite may reach the pulmonary arteries by the haematogenous route from the liver or it may arise from right cardiac lesions (2). Chest pain, dyspnea, hemoptysis, malaise, fever, acute cor pulmonale, or even sudden death may be seen.
In this article we present a case with bilateral multiple lung lesions related to pulmonary artery embolism with hydatid disease (HD). The patient’s chest X-ray and multide-tector computed tomography (MDCT) findings are shown.
C
ASER
EPORTA
76-year-old woman presented with a history of cough (2years), loss of appetite and weight (6 kg in 3 months). She had been expectorating serous sputum for 2 to 3 months, which had been more mucoid in the last few days. Thespu-tum was bloody two times in the week prior to admission. In the past, medical treatment had been recommended because of multiple pulmonary cysts. She had been treated with alben-dazole for 1.5 years. Unfortunately, she had ceased the thera-py 6 months before, when she felt well.
Systemic examination was unremarkable except for pale-ness and diminished breath sounds. Results of laboratory investigations were normal except for elevated CRP (2.79 mg/L) and sedimentation rate (64/hr) levels. Indirect hemag-glutination for HD was >1:2560 (+). The chest X- ray showed multiple different sized and shaped nodules with smooth borders distributed in both lungs (Figure 1). Contrast-enhanced MDCT disclosed few cavitary lesions in the upper lung zones and disseminated cystic lesions. Multiple serpentine, cystic lesions were seen in the mid and lower zones of the lungs. Some of them were occluding the branches of the pulmonary arteries and some were arising from the peripheral bronchial carinas and tracking the bron-chovascular bundles (Figure 2 A,B,C). On the upper abdomi-nal images, an exophytic partially calcified caudate lobe lesion was seen. It reached the inferior vena cava (IVC) and the right adrenal gland (Figure 3). The IVC was partially occluded with HD.
Albendazole treatment was given to the patient. Lung lesions waned after 2 months of treatment, but she com-plained of hemoptysis 2 to 3 times. The patient is still in fol-low-up at our chest disease outpatient clinic.
D
ISCUSSIONA
lthough pulmonary artery embolisms are usually detectedin patients with liver HD, isolated cases have also been reported (3). In all patients with liver lesions located near the IVC and/or hepatic veins, pulmonary artery involvement should be investigated with a systematic search (4). In our patient, an exophytic caudate lobe lesion lead to a pulmonary embolism via IVC. Multiple lung cysts may be associated with pulmonary artery embolism, as in our patient; however, these are not always present.Three clinical presentations have been described in hydatid cyst-related pulmonary artery embolism: protracted pulmonary hypertension, pulmonary hypertension leading to death within a year, and acute fatal disease related to massive embolism (5). Obliterating cystic lesions or postoperative granulomatous reaction and fibrosis may cause pulmonary hypertension. Early diagnosis and treatment may prevent pul-monary hypertension.
PROSTAT ADENOKARS‹NOM TANISI ALAN B‹R RS3PE OLGUSU
TÜRK GER‹ATR‹ DERG‹S‹ 2014; 17(3) 313
Figure 1— PA chest X-ray showing bilateral and multiple nodular lung
NONTHROMBOTIC PULMONARY ARTERY EMBOLISM IN AN ELDERLY PATIENT: HYDATID CYST
TURKISH JOURNAL OF GERIATRICS 2014; 17(3) 314
The diagnosis of pulmonary artery embolism due to HD depends on clinical and radiological findings. Serologic tests can be used to confirm infection. The most accurate imaging modality is MDCT. It provides volumetric rendering tech-niques that raise diagnostic capability. Multiplanar reformat-ted images and three-dimensional reconstructions permit the
exploration of fine anatomical detail and show extensions of the lesions and their relationships with pulmonary arteries. Accompanying heart, lung and liver lesions may be detected in a single scan. On contrast-enhanced MDCT scans, well-defined fluid attenuated cystic structures, partially or totally occluding the main pulmonary arteries with or without its
Figure 2— Coronal (A, B) and sagittal (C) reformatted MDCT maximum intensity projection images show low density cystic serpentine lesions (thick
arrow) in the mid and lower zones of the lungs. They were occluding the left lung upper lobe and right lung lower lobe segmental pulmonary arter-ies (thin arrow). In addition several peripheral parenchymal cysts are noted (arrowhead).
PROSTAT ADENOKARS‹NOM TANISI ALAN B‹R RS3PE OLGUSU
TÜRK GER‹ATR‹ DERG‹S‹ 2014; 17(3) 315
branches, are seen. Intra-arterial lesions may cause enlarge-ment of the vessel and an enhanceenlarge-ment of the cyst wall may be detected (1, 6).
Pulmonary thromboembolism, tumor embolism and pul-monary artery sarcoma should be evaluated in the differential diagnosis. Acute thromboembolism may mimic HD embolism with acute onset of chest pain, cough and hemopt-ysis. It may be excluded with patient’s medical history and a cystic filling defect in the pulmonary arteries on MDCT scan. Tumor embolisms usually occur in extrapulmonary malig-nancies such as sarcoma and breast, gastric, renal cell, prostate, hepatocellular, and choriocarcinoma. The specific signs that indicate tumor emboli in major branches are con-trast enhancement within the intra-arterial filling defect and a dilated and beaded appearance of the affected pulmonary arteries (7). Pulmonary artery sarcoma is an aggressive tumor, shows enhancement with contrast agents and almost always has mediastinal or parenchymal invasion when it is detected (1).
In proximal pulmonary intravascular HD, the definitive treatment is excision of the pulmonary artery cyst and if pos-sible extraction of the leading liver lesion. However, this treatment has several life-threatening risks. Patients should be informed about the rupture of the artery and/or the cyst, dissemination of the disease, anaphylactic shock, and pseudoaneurysm formation (2). In disseminated lung lesions and in patients who do not accept surgical intervention, med-ical therapy should be started.
In conclusion, in patients with pulmonary artery embolism, medical history should be investigated properly and HD should be kept in mind, especially in patients with liver echinococcosis. The definitive diagnosis and the dissem-ination of the disease can be accurately identified with MDCT.
R
EFERENCES1. Damiani MF, Carratù P, Tatò I, et al. Recurrent pulmonary embolism due to echinococcosis secondary to hepatic surgery for hydatid cysts. J Comput Assist Tomogr 2012;36(5):534-5. (PMID:22992602).
2. Akgun V, Battal B, Karaman B, et al. Pulmonary artery embolism due to a ruptured hepatic hydatid cyst; Clinical and radiologic imaging findings. Emerg Radiol 2011;18(5):437-9. (PMID:21494880).
3. Karantanas AH, Bitsios G, Karaiskou E. Echinococcus of the pulmonary artery; CT, MRI and MRA findings. Comput Med Imaging Graph 2000;24(4):265-7. (PMID:10842051). 4. Vinatier I, Rivaud E, Tcherakian C, et al. Nonthrombotic
pul-monary embolism. Eur Respir J 2010;35(1):224. (PMID:20044467).
5. Bayarogullari H, Davran R, Cavus Y, et al. Liver hydatid cyst leading to bilateral pulmonary artery embolism and bilateral multiple pulmonar echinococcosis via inferior vena cava; Report of a case. Clin Imaging 2013;37(2):374-8. (PMID:23465996). 6. Namn Y, Maldjian PD. Hydatid cyst embolization to the
pul-monary artery; CT and MR features. Emerg Radiol 2013;20(6):565-8. (PMID:23686588).
7. Pena E, Dennie C, Franquet T, Milroy C. Nonthrombotic pul-monary embolism; A radiological perspective. Semin Ultrasound CT MR 2012;33(6):522-34. (PMID:23168062). Figure 3— Axial contrast enhanced MDCT image showing partially
cal-cified exophytic liver hydatid cyst protruding and invading the IVC (arrow).
